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Making Tablets More Effective for Data Capture

Six months ago I wrote about the virtues of using an iPad Mini tablet in the patient care setting.  At that time I was using my tablet almost all day, every day for multiple purposes including EMR data capture.  Things went well for a while, but as time passed I used the tablet less and less.  Eventually I stopped using it almost altogether except for displaying and annotating CT images during patient visits.  At first I did not understand why.  Was the non-Retina display finally getting to my 50+ year old eyes?  Was the external microphone I used to improve speech recognition losing performance?  Was the battery fading after 9 months of charge / discharge cycles?  Or was the “gadget lust” of a new tech-toy finally wearing off?

Each of the above may be just a little bit true.  But two other reasons are most relevant to me.  First, my efforts to add a medical vocabulary to the embedded speech recognition failed.  But most importantly, I became frustrated with how difficult the tablet was to hold for extended periods of time.  When I wrote that the tablet was “easily and comfortably held by its edge” I was wrong.  Tablets are beautiful to behold, but their clean lines and smooth surfaces make holding them for extended periods of time very cumbersome.

So I created something that would fix the problem by making a tablet more comfortable and safe to hold.  Now that the provisional patent application is registered I can share the design:

                 figure 11                     

The photos are of a nonfunctional mockup I made out of Styrofoam, balsa wood and spackling compound.  It is a grip that attaches primarily to one edge of a tablet computer and facilitates holding the tablet by its edge rather than the back.  It is shaped to fit the hand and allows both proper hand positioning and proper viewing angle.  It provides a mechanical interface between the tablet edge and a semi-pronated (handshake position) hand/forearm.  Its purpose is to facilitate extended use of the tablet by minimizing orthopedic strain to the hand, wrist, forearm, elbow, shoulders and neck.   The interface with the remaining 3 edges is minimal, preserving the ability to store the tablet-grip assembly in a coat pocket.

The external shell is a composite of plastic, rubber, metal, leather or similar materials.     There may also be a thin covering over the back and/or front faces of the tablet for protection and mechanical stability.  The top side is contoured to engage the thumb and guide the thumb to the home button.   The bottom is contoured to engage the fingers.  This shape gives the thumb and fingers stability and purchase to counter the tablet’s weight and torque in the yaw and roll axes.  The gripped portion has bilateral symmetry to allow left hand or right hand grip.  Openings and mechanical and/or electronic pass-throughs provide access to tablet buttons, ports, etc.  It could also include a stand for self-support on a tabletop and a place to store a stylus.  Some panels could be customized for color, shape (i.e., for different hand sizes) or material.

There is space available within the grip to add hardware and enhance functionality.  Examples include – but are not limited to – extended battery, external microphone / speaker, Bluetooth keyboard interface (to make the composite device appear as a keyboard to an external workstation), wireless USB, and apps that use cloud-based speech to text capability.  Any companion software component – an app – would be loaded into the tablet itself.

I need your help both to estimate the potential of this idea and get some advice on what to do with it next.  If you think this is an idea worth pursuing give me a like on Facebook at the bottom of the article.  If you feel strongly about it give it a Tweet as well.  And if you have some advice I would be grateful to hear it.

 

February 27, 2014 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Six Years Later, What Has Meaningful Use Accomplished?

In Atlanta we are recovering from one of worst winter storms in many years. Weather events are financially devastating for a medical practice.  Revenue completely stops while expenses continue without interruption.   Today for the first time we saw patients in the office on a Saturday to recover a little.

During our 3 snow days this past week I decided to take on John Lynn’s challenge regarding what I would do if the Meaningful Use (MU) incentive money disappeared.  There has been a range of responses including one person who wouldn’t change a thing about MU.  However, recent data continue to support my long-held opinion that MU has been harmful to health IT and the EMR cause.

Think about where we were before MU was conceived.  Six years ago the NEJM study cited by the designers of MU showed a 4% EMR adoption rate.  Among EMR users the vast majority (72%-96%) reported a positive effect of EMR on patient care.  Among EMR users physician satisfaction was 93%.  Among EMR non-users, the major reasons for not getting an EMR included cost (66%), uncertainty regarding the return on investment (50%), and loss of productivity during implementation (41%).

Six years later, what has MU done for EMRs?  Medical Economics recently released an EHR survey of 967 physicians polled in late 2013 with very disturbing results:

  • 70% did not feel their EHR investment was worth the cost and the effort
  • 73% would not re-purchase their current system
  • 69% report coordination of care has not improved
  • 65% do not believe EHR has improved quality of care.  45% believe EHR has made patient care worse
  • 66% report financial losses resulting from EHR.  38% report significant losses.
  • Lack of system functionality was the most common complaint among EHR users (67%)
  • 45% of all physicians spent over $100,000 on EHR and 77% of the “largest” practices spent over $200,000.  It is unclear whether this is the total practice cost or cost per physician.  Increased staff costs and loss of productivity were also cited as major issues.

Also telling are data reported by CMS last May that a staggering 17% of all providers who attested for the 90 day period required for MU Stage 1 / Year 1 (2011) did not participate the following year.  A CMS survey of these “non-returning providers” (NRPs) showed many of them gave up for reasons related to the MU program as well as reasons related to dissatisfaction with their EMRs.

Analysis of these 3 studies suggests that the satisfaction rate among EMR users has fallen from over 90% to about 30% over the past 6 years.  The proportion of providers that believe EMR improves quality of care has fallen from 82% in 2008 to 35% in the 2013 ME survey.  The misgivings of non-EMR-users in the NEJM 2008 study were proven valid among the dissatisfied EMR-users in the ME 2013 survey: high cost, poor return on investment and loss of productivity.  Even 5 figure financial incentives can’t get MU / EMR participation beyond a very short time of 90 days.

How could EMR’s reputation among EMR users fall so far?  The Meaningful Use program is solely responsible.

Go back to 2008 for a moment.  Had the health IT market been left undisturbed, EMR vendors would have engaged their existing base of satisfied customers in order to improve their products and sell to new customers.  This base of early EMR adopters was unique and special.  Our practice was among those that had a fully functional EMR in 2007-2008.  We shared a vision and saw the potential for information technology to improve health care.   We had both the IT resources and the will to work hundreds of extra hours to build effective EMR systems from products that were almost useless as they came “out of the box.”  We willingly accepted that proposition.

In 2008 the early adopters would have gladly offered their own practices as examples to demonstrate the value of EMR and help their vendors sell to new customers.  This slow, evolutionary growth would have created a stable environment that allowed the health care system to safely assimilate the cultural and operational changes that EMR brings.  This environment would have also supported stable evolution and improvement of EMR products.  The result would have been modest but steady growth in the EMR market for decades to come.

But thanks to MU this never happened.  Replacement of stable, natural market forces with MU incentives drove immediate, explosive short-term growth in the EMR market.  But these MU-driven EMR purchasers are not like the practices before 2008 that freely chose to purchase a system. These practices had decided against EMR initially, at least partly because they lacked the IT resources to make EMR work for them.   MU coerced them to purchase EMR against their better judgment.

I have spoken with many of these physicians.  They do not share the inspiration and vision of the early adopters.  They are rightly unhappy and cynical, forced by MU to spend huge amounts of money on unproven, underdeveloped EMR products that they did not want and were not prepared to properly use. To these practices the question of EMR’s potential is irrelevant.  In their minds MU (and by association EMRs) lives next to HIPAA, SGR and RAC audits as another method for the government to intimidate doctors and intrude upon their practices.

The MU program gave EMR vendors what they wanted – legislation requiring hundreds of thousands of providers to buy EMR products, with no need to prove that those products do anything useful.  But here’s the bad news: the Feds got what they wanted as well.  Through MU they created an EMR industry that is dependent on government incentives and penalties to maintain a stream of new customers.  This gives them complete control of the EMR market.  There is more bad news.  MU also destroyed the base of satisfied EMR customers from 2008, replacing it with a much larger base of unhappy, resentful customers.

So what happens as MU payments decrease with each passing year as MU requirements go up?  Who can argue that the market won’t collapse without another EMR stimulus package?  John Lynn’s question is appropriate and timely.  MU incentives will indeed disappear over the next couple of years.  How the EMR market will survive is not clear.

February 15, 2014 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Web Portal Use by the Numbers

With our first year of web portal use well behind us I started looking for practical ways to begin mining some data to get some basic statistical observations regarding patient use of web portal.  As with all new undertakings in health IT this was far more difficult and cumbersome than it should have been.  Nonetheless I got a few interesting observations documented over the past couple of days.  I did not do an exhausting review but I don’t think data like this exist anywhere else.

I was curious about what proportion of our network’s new patients have used the web portal over the past 6 months.  Overall 22% of our new patients used the web portal for clinical data entry.  This differs significantly from my subjective observation that about half of my new patients were using the portal; this data includes all 19 of our network physicians, not just my own.  I am in the process of looking at my patients only.

 

The breakdown by age is here – the first table  – web portal figure 1

 

Portal use is very steady at around 25% through age 65 years.  Use among pediatric patients shows parents are just as willing to use the portal for their children as they are for themselves.  It is reasonable to expect portal use to drop with increasing age but I didn’t expect 65 year olds to be using the portal as much as 25 year olds.  Portal use among patients in their 70’s and 80’s is quite respectable.  The bump in use in patients over 90 years of age is interesting but likely to be a statistical illusion due to the very small absolute numbers in those age brackets.

 

The second table shows the same data expressed as raw numbers rather than percentages.  All our new patients, regardless of portal use, tend to be from age 40 to 70 years.

 

 

October 7, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Doctor’s Best Use of the Tablet

I recently reviewed the Epocrates 2013 Mobile Trends report.  The study has a somewhat unusual participant profile, consisting only of primary care, 3 medical specialties and no surgical specialties; nonetheless the observations are probably close to the mark and are consistent with my experience with my first tablet a couple of years ago.

I purchased an iPad within a couple of months of the introduction of the first model thinking it was perfect for EMR use in my office.  I abandoned it after a couple of months when I discovered several shortcomings.  First, the first iPad was too heavy to hold by the edge and had to be held by a fully supinated hand (totally flat palm facing up).  Try that for 5 minutes and see how your forearm feels.  The first iPad was also too big to put in a physician’s white coat pocket.  And the screen resolution of the first iPad models was not good enough to display a busy EMR screen.   But the biggest drawback was that the early remote desktop apps did not work very well.

The iPad mini addresses all four of these issues.   The Mini is small enough to fit in a white coat pocket with the standard magnetic cover in place.  It is easily and comfortably held by its edge.  It needs a Retina screen badly but the display is better than the original iPad and is (barely) adequate for my 50-year-old eyes to see.   And remote desktop apps have come a long way.  It appears that similar advances have been made in tablets from other manufacturers as well.

I was therefore surprised to learn from the Epocrates study that although a majority of providers (53%) use tablets for patient care related activities, only a small portion (2%) use tablets for actual patient care record keeping in an EMR.  So I thought it would be interesting to outline my current methods of using a tablet that put me in the 2% category as well as the 53%:

 

  • Entering data into my EMR via a Remote Desktop app.  There are important lessons here.  Don’t expect to stick a tablet in the physician’s hand and have it work like magic.  Our office workflow is designed to optimize the physician / tablet combination.  I use the tablet for only 2 data fields in EMR:  assessment and coding (CPT and ICD).  The office staff enters all the other parts of the note and initiates treatment workflow through the EMR at the physician’s direction.  After the patient is seen I review all parts of the note (on a laptop or desktop), make additions / corrections, and sign it.
  • Cloud based voice-to-text.  This takes the tablet from merely useful to spectacular. There are 3 characteristics of Apple’s built-in cloud-based speech recognition that make it comparable to the Dragon software I have used in various forms for over 10 years:  1.  It is embedded seamlessly into the soft keyboard, 2.  An inexpensive external microphone plugged into the headphone /microphone jack raises transcription accuracy tremendously, and 3.  It works well with Remote Desktop, eliminating the need for a “dictation box” or other similar workaround.  These attributes make up for its most serious drawback, the lack of a medical (or at least customizable) vocabulary.  At the moment I have the right people talking to each other to address that problem.
  • Hospital EMR.  Our hospital is still in the implementation phase of a new Cerner system.  I am still learning the system myself but my initial experience using the system on my tablet using Citrix Receiver has been very positive.
  • Patient education.  LUMA, a product of Eyemaginations, is a very nice product for showing surgical patients the complex head and neck anatomy of their diagnosis and/or proposed surgical procedure.  There are both online and iPad versions available.  I can switch back and forth between EMR and LUMA without losing the Remote Desktop connection.
  • Medical imaging.  I can’t load an image disk directly onto my tablet but I can load it onto my desktop and take a photo with my tablet to review relevant images with patients.  I have tinkered with some apps that allow me to draw on the image to help educate patients.  Still looking for a way to conveniently reduce the file size to facilitate copy-pasting into EMR notes.
  • Literature searches in the exam room.  Not glamorous but helpful, most commonly to review medication side effects.

 

I think that is a pretty complete use of the tablet for the physician.  No doubt new uses will appear before long.

 

August 27, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Our First Year with a Patient Portal

Last month marked the end of our first year with our web portal.  It has been a steep but worthwhile learning curve.  Similar to every other component of our IT system there were many bumps along the way.  Here are some observations worth sharing:

  1. If you build it – and promote it – they will come.  There is no question that patients in our North Atlanta market like the portal.  Over the first 12 months 12,518 patients have signed up and completed over 130,000 health, demographic and general consent forms.  Participation has increased steadily as we have refined web page usability and improved the reliability of the system.  Subjectively I think about 2/3 of my new patients are using the portal to enter their demographic and personal health information prior to their initial appointment.
  2. Overpromotion backfires.  Our telephone-greeting message says, “To schedule an appointment, dial 0 or go to www.entofga.com.”  Sounds reasonable enough, but patients have misinterpreted this message as meaning that we don’t want to talk to them.
  3. If it doesn’t work, patients get angry – with good reason.  Nothing is more frustrating than spending 45 minutes filling out all your information at home and then getting handed the same forms on paper at the office because your online data was lost.  The IT folks seem to think if the explanation for the failure is fancy enough that will make everything OK.  It doesn’t.
  4. Patients who choose not to use the portal at home don’t want to use it in the waiting room, either.  We have tried iPads, laptops and desktop kiosks.  We have trained our front office folks to promote it and even “walk patients through” the portal.  Nothing has worked.  We have considered recruiting those patients with a different technology such as scanned #2 lead pencil bubble forms, at least for the discrete data.
  5. Patients have little interest in using the portal as an ongoing tool.  After the initial creation of the account, data entry and first appointment, they rarely use the portal again.  Last month with over 12,000 patients enrolled we got only 6 prescription refill requests and 24 “ask the doctor” questions.   Appointment requests were slightly better at 134.  Our telephone appointment schedulers tell me they frequently get calls from folks who made an appointment request online but then immediately call for the same appointment because they were not comfortable with the online appointment concept.  One could argue that this is unique to our specialty practice or that the online forms and workflow need improving.  That may be true, but I am convinced that at least a part of this phenomenon represents cultural pushback from patients.
  6. The ROI on the web portal is in some ways an all-or-nothing situation.  For a while the portal was passing to EMR only about 15 of the 20 data fields required to complete our demographic database.  Intuitively one would think the portal was therefore “75% useful”.  The problem is if I have to pay staff to open the patient’s file to manually enter the 5 remaining fields, I may as well have them manually enter all 20 fields.  That makes the portal 0% useful.  I can’t reassign staff to better things until the portal passes 100% of the data to the EMR.  This also relates to the reliability issues described above.  Until we reach near 100% reliability the return on investment is limited.
  7. As with every health IT product we have ever tried, it doesn’t work completely as advertised.  Although the new patient workflow is going fairly well other features remain severely compromised.  In our vendor’s defense this is partly because our parent EMR has had some upgrades which in turn requires our vendor to update the portal to adapt to the EMR changes.  The point is that none of these products is “plug and play” and the industry has a long way to go before these products become easy to use and practical for everyone.
  8. There are unintended consequences of a web portal.  Unbeknownst to us our portal was directing patients to the vendor’s personal health record product.  The transition is apparently pretty seamless so patients often still thought they were still inside our portal when they encountered very personal questions (i.e., sexual history) that had no relevance to their ear / nose  / throat appointment.

As an “early adopter” practice we are pleased overall with the portal but I’m not sure how a more typical practice would feel.

August 11, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Economic Lessons of mHealth

I wrote this article for mHIMSS which was posted yesterday.  The original post is available here:

 

The recent HIMSS 2013 meeting witnessed the emergence of mHealth as a significant component of health information technology (HIT).  The meeting offered 35 educational sessions on mHealth. One of the meeting’s keynote speakers, Dr. Eric Topol, predicted a revolution in health care based on smartphones.  Connecting a smartphone to a currently available bio-sensor allows anyone to monitor and share with a physician his vital signs, heart rhythm, sleep patterns or blood sugar, and soon other physiologic data as well.  Eventually these systems will include software that will enable laypersons to interpret data and determine when physician involvement may be appropriate.  The way each of us will learn to interpret our own body’s data will become a natural extension of the way we now interpret our own “internal body cues” and symptoms.

Meanwhile, progress within the more established parts of HIT has ground to a standstill. At the HIMSS meeting results of a provider survey conducted by the American College of Physicians and AmericanEHR Partners were presented.  Among over 4000 surveys the percentage of clinicians that were “very dissatisfied” with their EMRs has increased by 10% from 2010 to 2012. 39% of EHR users would not recommend their EHR to a colleague (up from 24%).  Satisfaction with EMRs has clearly deteriorated since the 2008 pre-Meaningful-Use study published in NEJM that showed 93% of physicians were satisfied with their EMR.  In the physician blogosphere the leading EMR story last week was about a physician class-action lawsuit against an EMR vendor who allegedly sold defective software and then abandoned the product.  Outside of mHealth there is not a lot to cheer about in HIT right now.

Why is mHealth growing so fast while the rest of HIT is stalling? There are many reasons but three important reasons bear discussion.

First, most mHealth projects don’t take on every patient at once.  An mHealth project designed, for example, to monitor congestive heart failure patients at home addresses only that population of patients and providers associated with a single diagnosis. A project with such a narrow, focused scope has a greater chance of success than a typical EMR project which must cover every patient and every physician regardless of diagnosis.

The other two reasons illustrate an important economic lesson. At the moment mHealth is a relatively unregulated industry. Any startup company can acquire a bio-sensor and/or write a mobile app for a smartphone and be off and running.  There are no Meaningful-Use-type regulations that require all mHealth apps to operate a certain way or meet a minimum set of requirements.  Barriers to entry are relatively low.

Third, many mHealth projects are marketed directly to consumers and are paid for directly by consumers.  The just-released Samsung Galaxy S4 smartphone has a suite of built-in mHealth apps and available biosensors to monitor sleep, calories burned, heart rate and (Samsung implies) blood glucose.  Consumers will purchase this phone like any other – with their own money.  There are no third party payers involved.  That means no insurance approval, no complex coding and billing, no politics ….so far less overhead and far more flexibility and speed.  All you have to do is build a quality, useful product.

mHealth currently operates in a free market where products can be designed any way their creators choose. Their target customers choose what products to buy – or not to buy at all – and how much to pay.  Many of these products will fail, but the ones that succeed may indeed revolutionize healthcare as Dr. Topol predicts.

EMR vendors, burdened by Meaningful Use requirements, have little bandwidth left to address customers’ real needs.  As Meaningful Use requirements and EMR certification raise the barrier to entry into the market, the market is increasingly dominated by the largest vendors at the expense of the smaller ones.  As competition is suppressed product quality and customer service both suffer. Given the AmericanEHR survey results it is no surprise that EMR vendors are now marketing to current EMR users who are unhappy with their present system. There are certainly plenty of those.

Unfortunately the freedom mHealth enjoys may soon come to an end.  The FDA’s upcoming release of its final regulations of mobile medical applications is expected soon.  These rules will likely impose an approval process similar to those already in place for drugs and conventional medical devices.  One source estimates the cost of this approval process for a single mHealth product will be as high as $24 million.  While that estimate seems high, there is no doubt that the cost of compliance will have a detrimental effect on the mHealth marketplace.  Costs will go up dramatically, smaller companies will be forced out, and true innovation will slow as mHealth companies expend most of their resources on compliance.  Those products that survive to reach FDA approval will no doubt seek third party payor reimbursement.  With that will come loss of price transparency, driving up costs even further.  The mHealth market will become as bloated and ineffective as the rest of the health care system.

Will the mHealth revolution survive?  Time will tell.

March 22, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

mHealth is Coming of Age

Last week I had the pleasure of attending my first mHealth Summit in Washington, D.C.

The tone and rhetoric of this year’s meeting seemed a great deal different than what I read about last year’s meeting.  Gone was the doctor bashing by keynote speakers.  Instead we heard talks like the one from NIH director Dr. Francis Collins.   His literature review showed there are only 30 published, randomized, and controlled studies of mHealth technology.  Of those studies only 6 showed that mHealth showed a statistically significant improvement in patient care. He admonished the audience to subject mHealth technology to the same rigorous, statistically relevant testing that is given to other potential advances in health care.

Bravo.  Music to my ears.  That is something everyone in mHealth needs to hear.

Other speakers and panelists shared similar views.  I was also pleased to hear several acknowledgements of the critical role physicians must take in mHealth.  Until that point I had wondered if some mHealth proponents thought they needed doctors at all.

I was delighted to meet Arthur Lane, Director of Mobile Healthcare Solutions at Verizon Wireless.  Readers of my blog may recall I (unfavorably) reviewed Verizon’s home monitoring program for congestive heart failure (CHF) patients.   After discussing with Arthur my concerns about the program I realized we were very much on the same page.  He is aware of the literature, including the Yale study showing no benefit for home monitoring of CHF patients.  He has a very grounded approach to solving the issues raised by the medical literature.  That conversation changed my opinion of the project.  I like what they are doing.

I was also a panelist in a discussion entitled “Converting to mHealth: How to Drive Change”.  We had a very spirited discussion before a standing-room-only crowd.  I was very impressed with the moderator and the other panelists as well as the questions from the audience.  Much of the discussion addressed the relationship of doctors to health IT folks and the relative role of each in driving mHealth forward.  The discussion demonstrated that this is a complex issue with emotions on both sides.  I’ll have more to say about this in a future post.

It was gratifying to come home with my faith as least partially restored.  mHealth has matured over the past year.  And perhaps my own feelings about mHealth have matured as well.

 

 

December 11, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Naiveté of mHealth

Last week I attended a seminar on mHealth sponsored by the Technology Association of Georgia (TAG).  The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon Wireless.  He gave a nice presentation and video of a system Verizon is designing to improve care of congestive heart failure (CHF) patients after hospital discharge.  CHF patients are treated effectively in the hospital setting with closely monitored vital signs and carefully administered medications / diet.  The problem is that once the patient goes home it is difficult to maintain the same level of monitoring and precision of the medication / diet regimen.  As a result re-admission rates for CHF are high, adding to the cost of care.

The Verizon system claims to correct this problem with smart phone technology.  The video showed a smart phone reminding a CHF patient to weigh himself before bed.  He has gained ½ pound since the morning.  When he wakes up the next morning the phone again reminds him to weigh himself.  He has gained another pound.  Weight gain day-to-day is an indication that CHF is getting worse.  The phone sends the weight data to a server, which in turn notifies a provider to call the patient and somehow prevent him from getting worse and showing up in the ER.   It was never clear to me how the provider was going to fix worsening CHF over the phone.

After Mr. Lane completed his presentation he joined 3 other panelists for a lively discussion moderated by a local physician whom I know.  Some of these panelists described their devotion to mHealth with near breathless excitement.  The physician moderator posed the ever-present question to the panel:  “How do we get doctors interested in this system (and mHealth overall)?”  The answers ranged from good – “Give doctors a product that is cost-effective” – to the ridiculous – “Align incentives by making physicians join ACOs.”  The silliest thought of the night was the suggestion from one panelist that health care is no different from banking.  I left the meeting with some concerns about who would pay for the Verizon system but decided to hold my reaction until I did a literature review.  After all, I am no cardiologist and have not treated a patient for CHF since med school.

 My review did not yield good news for Verizon or mHealth.

Turns out physicians have been working on home monitoring for CHF patients for years.  Unfortunately their studies do not support remote home monitoring for CHF to reduce hospital admissions.  A study from Yale Medical School published in the New England Journal of Medicine in 2011 randomized over 1600 CHF patients to either a control group or a remote monitoring group for outpatient care following admission for CHF.  There were no differences in readmission rates for CHF or for any other cause over the 6-month study.  Several other studies, including comprehensive reviews of existing literature, reach similar conclusions.

So what would a more realistic mHealth video look like?

Our CHF patient is discharged from the hospital all tuned up with appropriate medications, diet and smart phone remote monitoring using a CHF app.  The monitoring app works well at first, feeding him periodic words of encouragement and reminders to take his meds, record his vital signs, weigh himself, etc.  After several days of his phone going off constantly with all the reminders, alert fatigue sets in.   After ignoring the alarms for a few days he gets fed up and shuts the CHF application off.  The monitoring network detects the data interruption, and a provider calls the patient.  At first the contact with a real human helps, but after several calls alert fatigue strikes again.  Our patient recognizes the caller ID and stops answering.

In the meantime he tires of his medication regimen and diet restrictions and succumbs to the urge to scarf down some pizza and beer with some potato chips for dessert.  His smart phone isn’t smart enough to change his behavior.  The salt and fluid load makes his heart failure worse.  In the middle of the night he wakes up short of breath and calls 911.  Back to the hospital he goes.

The mHealth community is so enamored with their toys they can’t see what is right in front of them:

  1. Peer-reviewed medical literature does not support the use of home monitoring for CHF patients.  Period.  LTE smart phones and glitzy medical apps do nothing to change that.
  2. Without supporting literature no one is going to pay for remote monitoring.
    Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate?  Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
  3. The mHealth folks fail to recognize that monitoring is not the endpoint.  The endpoint is changing patient behavior.  A smart phone constantly shrieking warnings and reminders is rendered useless by alert fatigue.  Patient behavior is a very tough nut to crack.  The Verizon video ends with a nurse talking to the monitored patient about his weight gain.  But that is NOT the end.  It is just the beginning.  No one knows what that nurse is supposed to say to change the patient’s behavior over the phone.
  4. Like many mHealth ideas this system creates unrecognized changes to the standard of care and thus changes medical liability.  What if our CHF patient who stops listening to alerts and stops answering the phone dies while he is in the monitoring program?  Who is liable?

 So it’s the same thing all over again with health IT.  No proof of effectiveness.  No way to pay for it.  No understanding of the medical challenges involved.  Unrecognized changes in standard of care and liability.  Health care is not the same as banking.  Duh.

 Verizon has no business getting into health care beyond the LTE connection itself.  They are going to lose their shirt investing in a treatment the literature says doesn’t work.  Perhaps unwittingly, the physician moderator said it best when he asked the panel, “Where is the app that slaps my hand when I reach for the bag of Oreo cookies?”

Don’t get me wrong, folks.  Our practice has enjoyed great success with EMR in over the past 7+ years.  Our experience just scratches the surface of the awesome potential of health IT.  I want you to succeed.  But the health IT industry is headed in a direction that will guarantee failure.  To succeed you must stop chasing pipe dreams and focus on the one goal that must be met before anything else – HIEs, mHealth or anything else – can succeed:

Find a reliable way for doctors to succeed with EMR in the office setting.  Upgrade EMRs to reflect some understanding of the practice of medicine.  Design patient portals that actually work.  Demonstrate that EMRs are effective at improving care.  Design a business model that shows the path to a return on investment.

Until that goal is met, nothing else matters.

October 5, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Secure Texting Scam

I fondly remember going deer hunting with my father and grandfather in Pennsylvania where I grew up.  We hardly ever actually killed anything.  One deer hunting technique we never used was called “putting on a drive.”   You start with a group of hunters at each end of the woods.  The first group does the “driving” by walking through the woods making lots of noise.  The other group lies hidden at the other end.  The first group scares the deer towards the second group for an easy blindside kill.  Even if you like hunting it’s not very sportsmanlike.  The deer don’t stand a chance.

Recent developments in health information technology convince me that Washington politicians and health IT vendors are putting a drive on physicians. Together they coerce physicians into technology purchases that may be redundant and unnecessary.  One such example is all the noise health IT vendors make about secure texting.

In November 2011 JCAHO posted a notice deeming the use of texting to communicate physician orders as unacceptable.   This very short statement offered two supporting arguments:  1.  The sender’s identity could not be verified, and 2.  There is no way to preserve the text message for the medical record.  The statement did NOT mention any potential for hacking, eavesdropping or any other privacy / security issue.

The following April a small (5 physician) cardiology practice was fined $100,000 for a number of HIPAA violations.  The worst of these was putting appointment and surgical schedules on a publicly accessible online calendar.  Other violations included failure to appoint a privacy officer and failure to conduct a risk analysis.  The HHS press release for this settlement does not list texting protected health information (PHI) as one of the violations.  Nonetheless many secure texting vendors have cited this settlement as evidence that the Feds are prosecuting providers for texting PHI.  My inbox has been inundated with ads: “Don’t get caught texting PHI!  Buy our secure texting product today!”

Many providers have drunk the Kool-Aid, succumbing also to strong intuitive – but unverified – arguments regarding SMS texting.  It is widely accepted that every text has at least 3 copies:  the sender phone, the receiver phone, and one or more copies on the telecom servers involved in the transmission.  The first 2 clearly exist.  But has anyone verified current practices among telecom providers regarding server storage of text messages?  There is no credible source that clearly documents what those practices are.  Many providers and IT folks also intuitively believe that text messages can be easily monitored / intercepted remotely.

One secure text vendor I reviewed offers secure texting for the “bargain” price of $10 per user per month.  For our practice that totals $12,000 per year.   The app requires installation on both sending and receiving ends, so even after all that money is spent I can text “securely” only to employees inside my practice.  Too bad I don’t need secure communication inside my practice.  My EMR already does that.  So the product is both expensive and useless.  Most secure text products are structured similarly.

The argument for secure texting products fails in several ways:

  1. The November 2011 JCAHO directive regarding texting of physician orders does not mention privacy as an issue.  The two issues it does raise, identity verification and documentation in the medical record, are not solved by secure text products.  Furthermore, the JCAHO arguments should apply to voice conversations as well.  The voice of a caller cannot be objectively identified, and voice conversations are not preserved for the record either.   Telephone orders have been the standard of care for decades.  We have tolerated those “shortcomings” without difficulty.
  2. No federal agency has investigated anyone for texting PHI – although the secure texting vendors would like you to believe otherwise.
  3. There have been no documented PHI security breaches related to texting.
  4. The biggest security issue for texting is the smart phones themselves, where stored text messages are just waiting to be lost or stolen with the phone.  Secure text products don’t solve that problem either.  This is more appropriately handled by password protecting phones and remote-erasing technology for lost or stolen phones.  There are lots of other ways to address the problem, such as storing text messages in the cloud rather than on the phone.
  5. Physicians have been using text communications for almost 20 years, since the advent of text-enabled pagers.  This far predates SMS technology.  We contacted our answering service regarding the security of the text-pages that they send to our smart phones.  We were assured that their secure server adequately addresses the issue.  Really?  Don’t their messages pass through the same telecom servers as other texts to reach our smart phones?  Am I missing something?
  6. Smart phones can be eavesdropped for both voice conversations and text using the same methods.  If the eavesdropping argument is used to outlaw unsecured text, then voice communications should be treated similarly.
  7. How exactly do the wireless carriers handle text messages?   Why isn’t anyone grilling them about securing their servers?  Current practice across the IT community is that the owner of a database is responsible for its security.  Verizon Wireless, starting last April, has expressed great interest in health care and has declared its intention to establish a role in the management of chronic diseases.  How about something simpler and much more useful…like secure texting for health care providers?

The “logical” conclusion – ignoring common sense – is that PHI would be prohibited in all wireless communications.  Doctors would have to return to 1980’s era pagers that only emit a tone.  You call the answering service – on a landline – to get the message.  The privacy policies made necessary by the Information Age would force us back to the Stone Age.

Instead consider the following plan that would serve PHI privacy needs without all the hysteria and expense of add-on products:

-       Establish a set of practices for texting medical information that avoids or minimizes the creation of PHI.  This would include referring to patients by initials and avoiding the use of identity-establishing information.  I have done this for the past few months and it works well.  You can include all the medical information you want in a text, but if the patient is identified only by initials then it is not PHI.

-       Engage telecom providers to establish adequate security measures for its servers.  They should be doing this anyway.  There would be many users willing to pay a reasonable amount to cover the expense.  This would be much better than add-on products since it would be compatible across all users.

-       Aggressively implement protection for smart phones, starting with mandatory password protection and remote erasing, and implementing more sophisticated technologies as they become practical and widely available.

How do you get a marginal product to sell?  Either have the government make people buy it (Meaningful Use) or use marketing sleight of hand to create the illusion of a legal imperative.  Secure text marketing strategy works just like the deer drive.  The “drivers” are the secure texting vendors.  They leverage poorly written and randomly enforced government regulations to make lots of noise in an attempt to scare physicians.  At the other end of the forest lurks Secure Texting Snake Oil – products that only pretend to rescue doctors from prosecution and patients from identity theft.  Their only true effect is to raise health care costs without any improvement in quality of care or data security.

September 6, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Unhealthy Side Effects of Meaningful Use

Author’s note:  This article appears in Townhall.com Finance today, co-authored by Dr. Hal Scherz and myself.

Imagine a world where fossil fuel vehicles are gradually outlawed in favor of electric cars. The government would at first give incentives to those who purchase electric cars and then gradually replace those incentives with penalties for cars that use fossil fuel. As implausible as this appears, it is already happening with light bulbs, toilets and wind turbines. The government fancies itself as entitled to decide what works best for everyone.

A similar process is currently ongoing with health information technology (HIT).  The Feds have appointed themselves as the final judge of how HIT should be used. The American Recovery and Reinvestment Act includes a set of  “Meaningful Use” (MU) guidelines for the use of HIT by physicians and hospitals.  Beginning in 2010 the Act offered physicians financial incentives for MU compliance; by 2015 the incentives will be replaced by penalties for failure to comply with MU.

The benefits of HIT to patients and doctors appear to be obvious.  The potential for improved medical record legibility, ease of access and reduction of medical errors is easy to appreciate. We all enjoy the advances that information technology has brought to our phones, cars, banks and airports. So a program meant to accelerate the adoption of HIT would seem benign enough.

But physicians who care for patients every day understand what no one else does – that the benefits of HIT are not a forgone conclusion.  To us HIT has as much potential to harm patients as it has to help them.  We also understand that the fund of knowledge required to safely and effectively implement HIT has not yet been adequately developed.  It is therefore foolish, even dangerous, to force HIT into widespread use before it is well understood.

There is surprisingly little evidence that the electronic medical record (EMR) improves quality of care. There is in fact some evidence to suggest that EMRs currently in use may actually reduce quality of care and raise health care costs.  There are also no established EMR implementation strategies for medical practices.  Implementing a complex EMR system into a busy medical practice is like replacing an aircraft’s engines while it is still flying.  During implementation there can be no reduction in patient volume and no errors in patient care.  Information technology is the only medical technology that has been given a “free pass,” with apparently no need to prove itself the way we prove the worthiness of new drugs, medical devices and surgical procedures.

HIT is also the only business technology in the entire economy that has been exempted from the need to show a return on investment. There is no recognized business model that makes HIT profitable, or even revenue-neutral.  Like any business a medical practice must survive financially. A practice cannot purchase and maintain HIT without a strategy to recover the investment.

Health information technology will change the practice of medicine more than any drug, imaging modality, operation or minimally invasive endoscope.  It will profoundly affect the care of every patient.  No other past or current medical advancement can make that claim.

Any new technology, including health information technology, produces unexpected adverse consequences.  For adverse events in health care government mandates create a frightening multiplier.  What if the government had required all overweight patients to use Fen-Phen before its cardiac side effects were discovered?  What if all patients with arthritic hips had been required to receive cobalt-containing implants?  In an environment where every innovation is rightfully scrutinized before it is placed into widespread use, why do so many accept the unproven claims of HIT as unchallenged fact?

The alliance between government and the HIT industry has replaced critical analysis with blind enthusiasm and has replaced innovation with mindless regulatory compliance. What would today’s technology look like if the government had decreed back in 1984 that we had to purchase 4 MHz PCs or first generation brick-sized cell phones? They would still be “state of the art” today.  Had there been government-mandated demand for these early technologies there would have been no reason to build smarter phones or faster computers.

Within the HIT industry Meaningful Use now dominates the discussion at the expense of creativity.  MU incentives have sucked all the oxygen out of the room where original thought once took place.  In a healthy environment, demand drives technology, not vice versa. If there were an electronic medical record that allowed physicians to provide better patient care and run their practices more efficiently, we docs would line up around the block at 4 AM to get our hands on it, just we all did for iPhones and iPads?   No incentives would be necessary.  Someday that will happen…but only after the government incentives are gone.

July 13, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.